New Client Registration Form Step 1 of 10 10% We’re excited to welcome you to the Thrive365 community! Once you are registered you will be able to search for staff and make direct booking requests. Not only will you be able to view their bio, you will also be able to view a special recorded message from the staff member. Thrive365 believe it is important that people know who they are choosing to support them and who is coming to their home all times. Before we get started, we have all new clients fill out this application. We’re going to ask a lot of questions and need information from you but don’t worry – you’ll only need to do this once! We will then do a check over and provide access to our staff platform so you can forge ahead and find your staff. While filling out your application it's important to know not to refresh the website page this will require you to start again. Once your application has been submitted on the last page, you will not be able to update or change your application currently without contacting Thrive 365 directly. If you have any questions along the way please contact our support team. Save and Continue Later Who are you seeking support for?MyselfSomeone else**For example, you might have a guardian, financial administrator, or care provider that makes important decisions for you.What is your name? First Middle Last What is your address? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone NumberMobile NumberWhat is your name? First Middle Last What is your address? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone NumberMobile NumberDate of Court Order if Applicable Date Format: DD slash MM slash YYYY Your Email* Enter Email Confirm Email Save and Continue Later Emergency ContactIf there is an emergency, who is the first person we should contact?Name First Last Home Phone NumberMobile Phone Number Save and Continue Later Our Support OptionsThrive365 is proud to offer a variety of services to help you or someone you care for.Please select all of the support services you need: (you can select more than one)* General household care In-home care Personal assistance Assistance while out and about in your community Education, training or employment Therapy services Transportation services to get you where you need to go Specialist support Supported independent living Save and Continue Later Support PlansDo you need help with mobility?YesNoPlease tell us about your ability to move independently. Include information about your ability to walk, climb stairs, use of walking aids, your ability to transfer, etc.Do you need support or help with processing information or other cognitive functions?YesNoTell us how you understand and process information. Also include details about your thinking process, your memory strength (both short and long-term), along with your self-awareness and awareness of others.Will you need help or support with communication with others?YesNoHow do you communicate with people? Tell us about your strengths and weakness in communication both verbally and written. Do you use any specific technique or methods the care worker should know about?Before one of our staff works with you, are there any habits or behaviors they should know about to help provide greater care?YesNoTell us about your habits and behaviors that could have an impact on [Client’s name} and other people. Give us as much detail as possible, and also include information about any management technique the care worker could use.Will you need personal care during the care giver’s shift?YesNoPersonal care can include a variety of activities including dressing, grooming, bathing and showering and more. Tell us what support you need and how you prefer it and we'll be happy to help.Will you need help with meals and eating?YesNoLet us know if you have any special mealtime needs such as preparing food or feeding.If you have personal goals you're striving to achieve, will our staff need to know about them?YesNoWe want to help you reach greater heights! Tell us about your goals along with ways we can help you get there.Are there any specific tasks or roles our staff will need to provide?YesNoHave specific tasks and needs? We’d like to know about them. If not mentioned in an answer above, please list them below. Save and Continue Later Personal Support in Your HomeIs your home difficult to find?YesNoPlease provide us with directions and other general information to help our staff find your home.Is parking available?YesNoPlease tell us where we should park to avoid disrupting your neighbourhood or location.Are there any special access gates or doorways that are difficult to access?YesNoPlease provide gate codes and other general information to help us enter your home.Is the entrance hard to find when it’s dark out?YesNoPlease provide general information to help us find your home at night.Are there any walking hazards in the home we need to avoid?YesNoNobody likes to trip or fall. Please let us know so we can look out for any obstacles.Will your care worker need to operate any of your mobility aids?YesNoIs your home wheelchair accessible?YesNoWill the support worker be required to use any electrical appliances?YesNoDo you have pets?YesNoWe love pets! Just make sure to provide any information we should know before we meet them. Save and Continue Later General Medical ConsiderationsPlease let us know about any specific medical concerns you have so we can work around them.Are seizures, choking, or anaphylaxis risks for you?YesNoPlease provide as much detail as you can about your risk for these emergencies along with instructions for your support worker.What allergies do you have?YesNoPlease list all allergies we should know about.*Will your care provider be responsible for administering medication?YesNoPlease list instructions and medication they will need to know about.Are there any other special medical considerations you’d like to share?YesNoPlease list any and all concerns you have including phobias and specific conditions. Save and Continue Later Your Safety ChecklistBy enlisting our services, you must affirm that your home will meet specific safety requirements. Please check off each of the following: Electrical appliances and power cords are in good condition and don’t pose any risk. Power cords are plugged into power boards and power sockets, but not double adapters. Your home is fitted with working smoke alarms. Your fuse box’s safety switch is in good working order. The support providers that come to your home won’t be exposed to cigarette smoke in your home. Save and Continue Later How would you like to pay for your support through Thrive365?Will you pay with NDIA funding?Note: We aren’t yet a registered provider in your state (we’re working on it though!). This means that we can only work with patients that are self-managed or under a plan.YesNoHow would you like to pay?Credit CardIn Person (Cash)OtherPayment Method Save and Continue Later How did you find out about Thrive 365?*Google SearchFacebookFriend/Family MemberOne of our clientsLinkedinI saw an adReferred by another partyYou’re almost done! Please confirm that the information in this registration is accurate and press submit when you’re ready!CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.